Download Depression - University of Sussex

Cognitive approaches to
treating emotional
disorders
Dr. Frances Meeten
[email protected]
OVERVIEW: Learning outcomes
- Understand two cognitive approaches to treating
depression.
 The context of cognitive therapies in relation to other
treatment options.
 Cognitive behavioural therapy (CBT) as a treatment for
depression.
 Mindfulness based cognitive therapy (MBCT) as a
treatment for depression.
Treatment options
DRUG THERAPIES
 Depression
1. Tricyclic drugs
2. Monoamine
oxidase inhibitors
3. Selective
serotonin
reuptake
inhibitors
(SSRIs)
PSYCHOTHERAPIES
COGNITIVE
BEHAVIOURAL THERAPY
(CBT)
PSYCHODYNAMIC
MINDFULNESS BASED
COGNITIVE THERAPY
(MBCT)
SYSTEMIC
(FAMILY)
Cognitive Behavioural Therapy (CBT)
One of the most extensively researched forms of
psychotherapy with over 325 outcome studies looking at CBT
effectiveness published in 2006 (Butler et al., 2006).
CBT encompasses a number of therapeutic cognitive and
behavioural approaches. The compelling evidence base for
CBT lead to an announcement in 2007 that there would be
£173 million into an Improving Access to Psychological
Therapies Program (IAPT) based on the finding that CBTs
were more efficient than pharmacotherapy or other
interventions (Rachman & Wilson, 2008).
Depression
Minor depression: Rumination on negative themes: Resentful,
irritable, or angry
Major depression: 5 or more symptoms in the last 2 weeks (Diagnostic
Criteria (DSM IV) Major Depressive Episode)
 Emotional changes: feelings of sadness and hopelessness.
 Cognitive changes: low self esteem, guilt, concentration difficulties.
 Behavioural and motivational difficulties: feeling slowed down,
reduced interest in social activities.
 Bodily changes: sleep, eating, loss of energy.
Chronic depression occurs in 15-39% of cases with individuals still
experiencing major depression one year after symptom onset (Berti,
Ceroni, et al., 1984).
Early experience
• e.g. rejection
and criticism
from parents
Negative core
beliefs/schemas
Beck’s cognitive model
- Recap.
From Dozois & Beck (2008)
• I am
incompetent
Negative life event
Activation of
schema
Cognitive biases
• Nothing ever goes
right for me
Negative automatic
thoughts
Depression
Structured:
• Time limited
• Problem orientated
Role of therapist:
• As a guide
• As a scientist
practitioner
• Socratic method
CBT STRUCTURE
Cognitive techniques:
• Hot cognitions
Recording cognitions
(mood diaries)
• Identifying
cognitive biases
Behavioural techniques:
• Behavioural
experiments
• Experiments with
therapist
• Experiments alone
From: Westbrook, Kennerley, & Kirk (2007)
Cognitive techniques
Cognition: “either a thought or a visual image that you may not be very
aware of unless you focus your attention on it” (Beck et al., 1979, p. 147)
The C in CBT
Help clients observe and record thoughts and images that
run through their minds and help them to distinguish
between thoughts and feelings.
For example
• Identifying ‘hot cognitions’: Rapid automated decisions
based on significant emotions.
• Identifying: ‘cognitive biases/ thinking errors’
Extreme thinking : Dichotomous thinking or unrealistic
biases.
Selective attention: Overgeneralization or disqualifying the
positive.
Example of techniques used to help people understand the
link between thoughts and emotions
Daily Thought Record
Date &
time
Situation
What mood
were you in?
How intense was the
mood?
0
10
Not at all
Very
Thoughts
Behavioural techniques/experiments
The B in CBT
Planned experimental activities, performed in or between
cognitive therapy sessions. (Bennett-Levy et al., 2004)
Their design is derived from a cognitive formulation of the problem
and their primary aims are:
1. Test validity of clients existing beliefs about themselves, others,
world.
2. Construct new, more adaptive beliefs.
3. Contribute to the development of the cognitive formulation.
(Bennett-Levy et al., 2004)
In depression, behavioural experiments may be used to test
negative automatic thoughts and to re-evaluate underlying
beliefs and assumptions.
Behavioural experiments
One example: Emma became depressed in university and dropped out when the
pressure of exams became too much. She moved back to her parents’ house and
felt too depressed to contact her friends.
Hypothesis testing
Theory A: Client’s initial belief: ‘My friends will think I am thoughtless and selfish
and won’t want to know me’ - 80% belief.
Theory B: Alternative belief: ‘One or two of my friends may be missing me, a
couple have tried to contact me’ – 20% belief.
Prediction: My best friend won’t want to know me any more. Even if we do meet I
will probably feel foolish and cry all night.
Outcome: After two more sessions working on the idea that the alternative belief
may be true, Emma picked up the phone and rang her friend. Her friend was
pleased to hear from her, they arranged to go out and Emma was surprised to find
that she had fun and did not cry.
Emma’s belief that her friend’s wouldn’t want to know her dropped to 10%.
Common CBT goals
1.The client needs to counteract negative cognitive
biases and develop a more balanced view of
him/herself, the world, and the future.
2. Restore activity levels, especially of activities that
bring a sense of pleasure and achievement.
3. Increase active engagement with problem
solving.
Efficacy of CBT for depression

Based on clinical trials evidence – NICE recommends CBT for depression
http://www.nice.org.uk/cg90

Important questions to consider when thinking about efficacy:
1.
2.



What is CBT compared to? Drug treatments, other therapeutic approaches,
nothing?
Long term outcomes: Are treatment gains maintained over time?
CBT is more effective than no intervention
 Based on meta-analysis of 97 studies, d = 0.67, Cuijpers et
al., 2011
Is equally effective as other types of psychological therapy
 Based on meta-analysis of 56 studies, d = 0.03, Cuijpers et
al., 2011
CBT is equally effective to antidepressant medication, and may
be more effective at preventing relapse (De Rubeis et al., 2005)
Efficacy of CBT for depression
De Rubeis et al (2005) Study comparing cognitive therapy with antidepressant
medication in adults
No difference in outcomes at 16 weeks
Cognitive Therapy was associated with lower
rates of relapse
Mindfulness Based Cognitive Therapy
(MBCT)
MBCT aims to prevent depressive relapse by developing
awareness of and changing the relationship with unwanted
negative thoughts, feelings and bodily sensations.
In this way previously depressed individuals respond to negative
thoughts not in an automatic way, but in a skilful intentional
way.
Ma & Teasdale (2004)
Mindfulness
“Paying attention in a particular way: on purpose, in the present
moment , and nonjudgmentally ” Kabat-Zinn (1990)
Core assumptions of MBCT
MBCT assumes that once in a mode of recovery from depression, previously
depressed individuals will still be vulnerable to experiencing low mood and
patterns of negative thinking.
Reactivation of depression related thoughts, feelings, and physical sensations
is often automatic – and can trigger relapse.
Model underlying development of MBCT for depressive relapse
Negative
thinking:
Depressive
episode
Nonnegative
thinking:
Remission
Potential
RELAPSE
Negative thinking
patterns “nipped in the
bud ”
Negative thinking patterns
re-established.
From: Segal, Williams, & Teasdale (2002), p. 37
LOW MOOD
Reactivation of
negative thinking
How does it work?
“The aim of the program is freedom, not happiness”
(Segal, Williams, & Teasdale, 2002, p.91)
8 week manualised course : Mindfulness practices and traditional cognitive therapy
techniques
AIM: To prevent re-establishment of patterns of negative thinking
Core themes
• Recognition of patterns of negative thinking e.g. ‘automatic pilot’
& ‘attachment to achieving happiness’.
• How to step out of old cognitive routines e.g. ‘decentring &
‘mindful awareness’.
• Experiential learning e.g. engaging in ‘being’ not ‘doing’ mode (in
class and through homework.
• Empowerment and acceptance/kindly awareness.
Mindfulness practice
In MBCT emphasis is placed on providing participants with opportunities to
relate mindfully and directly to their experience – this is done through a
series of meditation based exercises:
•
Body Scan
•
3 minute breathing space
• Mindfulness of the breath
These practices teach how
quickly the mind shifts from one
topic to another and – having
noticed that the mind is
wandering, how to bring it back
to a single focus.
Once the participant becomes aware of normally unnoticed mind
wanderings they use awareness to become vigilant of mood shifts either
by acceptance (allowing them to be there in a non-judgemental way), or
by employing a strategy to deal with negative thinking.
(Segal, Williams, & Teasdale, 2002)
Comparing MBCT and CBT
Practical differences:
MBCT delivered in a group format whereas CBT is often 1:1
MBCT is based on an 8 week program
Theoretical differences:
CBT encourages individuals to identify and change maladaptive thoughts
by challenging the accuracy of their beliefs.
MBCT teaches individuals to recognise the occurrence of depressive
thoughts without emotionally responding to them.
(Manicavasgar, Parker, & Perich, 2011)
MBCT includes techniques and exercises from cognitive behavioural
therapy with additional meditation components.
(Segal, Williams, & Teasdale, 2002)
Both MBCT and CBT include didactic elements, which provides the
participants with information about depression to facilitate them in
recognising and dealing with their relapse signatures.
Is it effective?
•
NICE recommends MBCT for depressive relapse:
http://www.nice.org.uk/cg90
•
In individuals who had > 3 episodes of depression
relapse was reduced when compared to TAU. (Ma &
Teasdale, 2000, 2004)
•
MBCT shown to be more effective than m-ADM at
preventing relapse. (Kuyken, 2008)
•
MBCT has shown promise for those still currently
depressed or experiencing chronic depression. (Kenny
& Williams, 2007; Kingston et al., 2007)
MBCT Summary
• MBCT aims to target relapsing depression and help people
to stay well over the long term by changing the physical
and psychological relationship with depression.
• Integrates cognitive therapy principles and practice into a
mindfulness framework.
• Provides a structured 8 session program to foster a
decentred relationship to experience.
• Negative thoughts and feelings are viewed as events in the
mind rather than ‘true’ statements about oneself.
One size does not fit all!
• The ‘alphabet soup’ of cognitive therapeutic approaches
grows.
•
Cognitive therapy is intuitively attractive due to a large
evidence base supporting its use, but some are unable or
unwilling to engage.
• How do we best deliver therapy? Will computerised
packages become popular?
•
MBCT requires time, commitment, and the willingness to
meditate.
Summary
• A range of cognitive approaches are available in the UK
• CBT has one of the largest evidence bases
Both cognitive and behavioural techniques help the individual
to develop strategies for managing problems and guide the
development of more adaptive perspective on the world.
• MBCT has been developed to break the cycle of relapse
common to depression
Techniques teach individuals to be present, in the moment,
to recognise negative thinking and decentre from it.
Compassion and kindness to the self are fostered.
References
CBT
•
•
•
•
•
•
•
•
•
•
•
•
•
Bennett-Levy, J., Butler, G., Fennell, M., Hackmann, A., Mueller, M. & Westbrook, D.
(2004) The Oxford guide to behavioural experiments in cognitive therapy. Oxford:
Oxford University Press.
Butler, A. C. Chapman, J. E. Forman, E. M. & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: a review of metaanalyses. Clinical Psychology Review, 26, 17-31).
Cuijpers P, Clignet F, van Meijel B, van Straten A, et al. (2011). Psychological treatment of depression in inpatients: a systematic review
and meta-analysis. Clinical Psychology Review 31(3):353-60.
DeRubeis, R. J., Hollon, S. D., Amsterdam, J.D., Shelton, R. C., Young, P. R., Salomon, R.
M., et al. (2005). Cognitive therapy vs. medications in the treatment of
moderate to severe depression. Archives of General Psychiatry, 62, 409-416.
Dozois, D.J.A. & Beck, A.T. (2008). Cognitive schemas, beliefs, and assumptions. In K.S. Dobson & D.J.A. Dozois (Eds.), Risk factors in
depression. London Academic Press. (Available online via ScienceDirect).(Nice explanations of main factors of cognitive model of
depression)
Rachman S, Wilson GT. (2008). Expansion in the provision of psychological treatment in the United Kingdom. Behaviour Research &
Therapy, 46(3), 293-5.
Westbrook, D. Kennerley, H. & Kirk, J. (2007). An introduction to Cognitive Behaviour Therapy: Skills and application. Sage. London
MBCT
Kenny, M. A., & Williams, J. M. G. (2007). Treatment-resistant depressed patients show a good response to mindfulness-based Cognitive
Therapy. Behaviour Research and Therapy, 45, 617-625.
Kingston, T., Dooley, B., Bates, A., Lawlor, E., & Malone, K. (2007). Mindfulness-based cognitive therapy for residual depressive
symptoms. Psychology and Psychotherapy, 80 (2), 193- 203.
Kuyken, W., Byford, S., Taylor, R.S., Watkins, E.R., Holden, E.R., White, K., Barrett, B., Byng, R., Evans, A., Mullan, E. & Teasdale,
J.D. (2008). Mindfulness-based cognitive therapy to prevent relapse in recurrent depression. Journal of Consulting and Clinical Psychology
76(6), 966-978.
Ma, S.H., & Teasdale, J.D. (2004). Mindfulness-based cognitive therapy for depression: Replication and exploration of differential relapse.
Journal of Consulting and Clinical Psychology, 72, 31-40.
Manicavasgar, V. Parker, G. & Perich, T. (2011). Mindfulness-based cognitive therapy vs cognitive behaviour therapy as a
treatment for non-melancholic depression. Journal of Affective Disorders, 130, 138–144.
Segal, Z.V., Williams, J.M.G., & Teasdale, J.D. (2002). Mindfulness-based cognitive therapy for depression: A New Approach to Preventing
Relapse. New York: Guilford.